Postoperative complications of xenogenic dural substitutes in hemicraniectomy

Decompressive hemicraniectomy (DHC) is a treatment option for refractory intracranial pressure (ICP) elevation in cases of cerebral infarction, hemorrhage, and traumatic brain injury. Several surgical techniques are used for musculocutaneous, bony, and dural exposure. The method of dural closure, specifically whether to use expanding duraplasty with or without xenogenic dural substitutes, remains a topic of debate. This study focuses on the occurrence of postoperative surgical side effects associated with these approaches. A total of 258 patients (mean age 52.8 ± 16.7 years; 140 male, 118 female, 79 infarctions, 57 traumatic brain injuries, 55 subarachnoid hemorrhages, 32 intracranial hemorrhages, 30 subdural hematomas, 5 other indications) who underwent DHC between 2015 and 2024 at our institution were reviewed. Complete clinical and radiological data were available for all patients. The patient population was divided into two groups: • Group A: 201 patients who received the xenogenic dural substitute. • Group B: 57 patients who did not receive a dural substitute. Baseline demographics (age, gender, underlying pathology) were comparable between both groups. No significant differences were found in the following parameters: • Duration of DHC surgery: 102.0 min (Group A) vs. 108.0 min (Group B); p = 0.24. • Postoperative CSF leakage: 3.5% (7/201) in Group A vs. 3.6% (2/55) in Group B; p = 0.96. Postoperative shunt dependency: 17.7% (35/198) in Group A vs. 16.4% (9/55) in Group B; p = 0.82. • Postoperative bleeding: 3.5% (7/198) in Group A vs. 5.5% (3/55) in Group B; p = 0.52. • Postoperative wound infections: 7.1% (14/198) in Group A vs. 1.8% (1/55) in Group B; p = 0.14. Cranioplasty was performed in 55.8% (110/197) of the patients in Group A and in 44.4% (24/54) in Group B. The use of xenogenic dural substitutes did not significantly affect the duration of cranioplasty surgery (114.2 min vs. 117.6 min; p = 0.72) or the cranioplasty results. However, the combined wound infection rate for both DHC surgery and cranioplasty showed a trend towards higher wound infection rates in patients who received xenogenic substitutes: • Combined wound infection rate: 11.6% (23/198) in Group A vs. 3.5% (2/57) in Group B; p = 0.07. The use of xenogenic substitutes may not significantly impact the prevention of postoperative complication profile with or without the usage of xenogenic dural substitutes in DHC. However, there was a trend towards a higher incidence of postoperative infectious complications in patients who received xenogenic dural substitutes.